Metabolic tumour volume in Hodgkin lymphoma-A comparison between manual and AI-based analysis

AIM

To compare total metabolic tumour volume (tMTV), calculated using two artificial intelligence (AI)-based tools, with manual segmentation by specialists as the reference.

METHODS

Forty-eight consecutive Hodgkin lymphoma (HL) patients staged with [18F] fluorodeoxyglucose positron emission tomography/computed tomography were included. The median age was 35 years (range: 7-75), 46% female. The tMTV was automatically measured using the AI-based tools positron emission tomography assisted reporting system (PARS) (from Siemens) and RECOMIA (recomia.org) without any manual adjustments. A group of eight nuclear medicine specialists manually segmented lesions for tMTV calculations; each patient was independently segmented by two specialists.

RESULTS

The median of the manual tMTV was 146 cm3 (interquartile range [IQR]: 79-568 cm3) and the median difference between two tMTV values segmented by different specialists for the same patient was 26 cm3 (IQR: 10-86 cm3). In 22 of the 48 patients, the manual tMTV value was closer to the RECOMIA tMTV value than to the manual tMTV value segmented by the second specialist. In 11 of the remaining 26 patients, the difference between the RECOMIA tMTV and the manual tMTV was small (<26 cm3, which was the median difference between two manual tMTV values from the same patient). The corresponding numbers for PARS were 18 and 10 patients, respectively.

CONCLUSION

The results of this study indicate that RECOMIA and Siemens PARS AI tools could be used without any major manual adjustments in 69% (33/48) and 58% (28/48) of HL patients, respectively. This demonstrates the feasibility of using AI tools to support physicians measuring tMTV for assessment of prognosis in clinical practice.

Artificial intelligence could alert for focal skeleton/bone marrow uptake in Hodgkin's lymphoma patients staged with FDG-PET/CT

To develop an artificial intelligence (AI)-based method for the detection of focal skeleton/bone marrow uptake (BMU) in patients with Hodgkin’s lymphoma (HL) undergoing staging with FDG-PET/CT. The results of the AI in a separate test group were compared to the interpretations of independent physicians. The skeleton and bone marrow were segmented using a convolutional neural network. The training of AI was based on 153 un-treated patients. Bone uptake significantly higher than the mean BMU was marked as abnormal, and an index, based on the total squared abnormal uptake, was computed to identify the focal uptake. Patients with an index above a predefined threshold were interpreted as having focal uptake. As the test group, 48 un-treated patients who had undergone a staging FDG-PET/CT between 2017–2018 with biopsy-proven HL were retrospectively included. Ten physicians classified the 48 cases regarding focal skeleton/BMU. The majority of the physicians agreed with the AI in 39/48 cases (81%) regarding focal skeleton/bone marrow involvement. Inter-observer agreement between the physicians was moderate, Kappa 0.51 (range 0.25–0.80). An AI-based method can be developed to highlight suspicious focal skeleton/BMU in HL patients staged with FDG-PET/CT. Inter-observer agreement regarding focal BMU is moderate among nuclear medicine physicians.

Deep learning-based quantification of PET/CT prostate gland uptake: association with overall survival

Aim

To validate a deep‐learning (DL) algorithm for automated quantification of prostate cancer on positron emission tomography/computed tomography (PET/CT) and explore the potential of PET/CT measurements as prognostic biomarkers.

Material and methods

Training of the DL‐algorithm regarding prostate volume was performed on manually segmented CT images in 100 patients. Validation of the DL‐algorithm was carried out in 45 patients with biopsy‐proven hormone‐naïve prostate cancer. The automated measurements of prostate volume were compared with manual measurements made independently by two observers. PET/CT measurements of tumour burden based on volume and SUV of abnormal voxels were calculated automatically. Voxels in the co‐registered ¹⁸F‐choline PET images above a standardized uptake value (SUV) of 2·65, and corresponding to the prostate as defined by the automated segmentation in the CT images, were defined as abnormal. Validation of abnormal voxels was performed by manual segmentation of radiotracer uptake. Agreement between algorithm and observers regarding prostate volume was analysed by Sørensen‐Dice index (SDI). Associations between automatically based PET/CT biomarkers and age, prostate‐specific antigen (PSA), Gleason score as well as overall survival were evaluated by a univariate Cox regression model.

Results

The SDI between the automated and the manual volume segmentations was 0·78 and 0·79, respectively. Automated PET/CT measures reflecting total lesion uptake and the relation between volume of abnormal voxels and total prostate volume were significantly associated with overall survival (P = 0·02), whereas age, PSA, and Gleason score were not.

Conclusion

Automated PET/CT biomarkers showed good agreement to manual measurements and were significantly associated with overall survival.

Automated quantification of reference levels in liver and mediastinal blood pool for the Deauville therapy response classification using FDG-PET/CT in Hodgkin and non-Hodgkin lymphomas

BACKGROUND

18F-FDG-PET/CT has become a standard for assessing treatment response in patients with lymphoma. A subjective interpretation of the scan based on the Deauville 5-point scale has been widely adopted. However, inter-observer variability due to the subjectivity of the interpretation is a limitation. Our main goal is to develop an objective and automated method for evaluating response. The first step is to develop and validate an artificial intelligence (AI)-based method, for the automated quantification of reference levels in the liver and mediastinal blood pool in patients with lymphoma.

METHODS

The AI-based method was trained to segment the liver and the mediastinal blood pool in CT images from 80 lymphoma patients, who had undergone 18F-FDG-PET/CT, and apply this to a validation group of six lymphoma patients. CT segmentations were transferred to the PET images to obtain automatic standardized uptake values (SUV). The AI-based analysis was compared to corresponding manual segmentations performed by two radiologists.

RESULTS

The mean difference for the comparison between the AI-based liver SUV quantifications and those of the two radiologists in the validation group was 0·02 and 0·02, respectively, and 0·02 and 0·02 for mediastinal blood pool respectively.

CONCLUSIONS

An AI-based method for the automated quantification of reference levels in the liver and mediastinal blood pool shows good agreement with results obtained by experienced radiologists who had manually segmented the CT images. This is a first, promising step towards objective treatment response evaluation in patients with lymphoma based on 18F-FDG-PET/CT.

A prospective study to evaluate the intra-individual reproducibility of bone scans for quantitative assessment in patients with metastatic prostate cancer

BACKGROUND

The Bone Scan Index (BSI) is used to quantitatively assess the total tumour burden in bone scans of patients with metastatic prostate cancer. The clinical utility of BSI has recently been validated as a prognostic imaging biomarker. However, the clinical utility of the on-treatment change in BSI is dependent on the reproducibility of bone scans. The objective of this prospective study is to evaluate the intra-patient reproducibility of two bone scan procedures performed at a one-week interval.

METHODS

We prospectively studied prostate cancer patients who were referred for bone scintigraphy at our centres according to clinical routine. All patients underwent two whole-body bone scans: one for clinical routine purposes and a second one as a repeated scan after approximately one week. BSI values were obtained for each bone scintigraph using EXINI bone^BSI software.

RESULTS

A total of 20 patients were enrolled. There was no statistical difference between the BSI values of the first (median = 0.66, range 0-40.77) and second (median = 0.63, range 0-22.98) bone scans (p = 0.41). The median difference in BSI between the clinical routine and repeated scans was - 0.005 (range - 17.79 to 0). The 95% confidence interval for the median value was - 0.1 to 0. A separate analysis was performed for patients with BSI ≤ 10 (n = 17). Differences in BSI were smaller for patients with BSI ≤ 10 compared to the whole cohort (median - 0.1, range - 2.2-0, 95% confidence interval - 0.1 to 0).

CONCLUSIONS

The automated BSI demonstrated high intra-individual reproducibility for BSI ≤ 10 in the two repeated bone scans of patients with prostate cancer. The study supports the use of BSI as a quantitative parameter to evaluate the change in total tumour burden in bone scans.

Evaluation of changes in Bone Scan Index at different acquisition time-points in bone scintigraphy

Bone Scan Index (BSI) is a validated imaging biomarker to objectively assess tumour burden in bone in patients with prostate cancer, and can be used to monitor treatment response. It is not known if BSI is significantly altered when images are acquired at a time difference of 1 h. The aim of this study was to investigate if automatic calculation of BSI is affected when images are acquired 1 hour apart, after approximately 3 and 4 h. We prospectively studied patients with prostate cancer who were referred for bone scintigraphy according to clinical routine. The patients performed a whole-body bone scan at approximately 3 h after injection of radiolabelled bisphosphonate and a second 1 h after the first. BSI values for each bone scintigraphy were obtained using EXINI boneBSI software. A total of 25 patients were included. Median BSI for the first acquisition was 0·05 (range 0-11·93) and for the second acquisition 0·21 (range 0-13·06). There was a statistically significant increase in BSI at the second image acquisition compared to the first (P<0·001). In seven of 25 patients (28%) and in seven of 13 patients with BSI > 0 (54%), a clinically significant increase (>0·3) was observed. The time between injection and scanning should be fixed when changes in BSI are important, for example when monitoring therapeutic efficacy.

3D skeletal uptake of 18F sodium fluoride in PET/CT images is associated with overall survival in patients with prostate cancer

BACKGROUND

Sodium fluoride (NaF) positron emission tomography combined with computer tomography (PET/CT) has shown to be more sensitive than the whole-body bone scan in the detection of skeletal uptake due to metastases in prostate cancer. We aimed to calculate a 3D index for NaF PET/CT and investigate its correlation to the bone scan index (BSI) and overall survival (OS) in a group of patients with prostate cancer.

METHODS

NaF PET/CT and bone scans were studied in 48 patients with prostate cancer. Automated segmentation of the thoracic and lumbar spines, sacrum, pelvis, ribs, scapulae, clavicles, and sternum were made in the CT images. Hotspots in the PET images were selected using both a manual and an automated method. The volume of each hotspot localized in the skeleton in the corresponding CT image was calculated. Two PET/CT indices, based on manual (manual PET index) and automatic segmenting using a threshold of SUV 15 (automated PET15 index), were calculated by dividing the sum of all hotspot volumes with the volume of all segmented bones. BSI values were obtained using a software for automated calculations.

RESULTS

BSI, manual PET index, and automated PET15 index were all significantly associated with OS and concordance indices were 0.68, 0.69, and 0.70, respectively. The median BSI was 0.39 and patients with a BSI >0.39 had a significantly shorter median survival time than patients with a BSI <0.39 (2.3 years vs not reached after 5 years of follow-up [p = 0.01]). The median manual PET index was 0.53 and patients with a manual PET index >0.53 had a significantly shorter median survival time than patients with a manual PET index <0.53 (2.5 years vs not reached after 5 years of follow-up [p < 0.001]). The median automated PET15 index was 0.11 and patients with an automated PET15 index >0.11 had a significantly shorter median survival time than patients with an automated PET15 index <0.11 (2.3 years vs not reached after 5 years of follow-up [p < 0.001]).

CONCLUSIONS

PET/CT indices based on NaF PET/CT are correlated to BSI and significantly associated with overall survival in patients with prostate cancer.

Association of PET index quantifying skeletal uptake in NaF PET/CT images with overall survival in prostate cancer patients

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Background: Bone Scan Index (BSI) derived from 2D whole-body bone scans is considered an imaging biomarker of bone metastases burden carrying prognostic information. Sodium fluoride (NaF) PET/CT is more sensitive than bone scan in detecting bone changes due to metastases. We aimed to develop a semi-quantitative PET index similar to the BSI for NaF PET/CT imaging and to study its relationship to BSI and overall survival in patients with prostate cancer. Methods: NaF PET/CT and bone scans were analyzed in 48 patients (aged 53-92 years) with prostate cancer. Thoracic and lumbar spines, sacrum, pelvis, ribs, scapulae, clavicles, and sternum were automatically segmented from the CT images, representing approximately 1/3 of the total skeletal volume. Hotspots in the PET images, within the segmented parts in the CT images, were visually classified and hotspots interpreted as metastases were included in the analysis. The PET index was defined as the quotient obtained as the hotspot volume from the PET images divided by the segmented bone tissue volume from the CT images. BSI was automatically calculated using EXINIboneBSI. Results: The correlation between the PET index and BSI was r2= 0.54. The median BSI was 0.39 (IQR 0.08-2.05). The patients with a BSI ≥ 0.39 had a significantly shorter median survival time than patients with a BSI < 0.39 (2.3 years vs. not reached after 5 years). BSI was significantly associated with overall survival (HR 1.13, 95% CI 1.13 to 1.41; p < 0.001), and the C-index was 0.68. The median PET index was 0.53 (IQR 0.02-2.62). The patients with a PET index ≥ 0.53 had a significantly shorter median survival time than patients with a PET index < 0.53 (2.5 years vs. not reached after 5 years). The PET index was significantly associated with overall survival (HR 1.18, 95% CI 1.01 to 1.30; p < 0.001) and C-index was 0.68. Conclusions: PET index based on NaF PET/CT images was correlated to BSI and significantly associated with overall survival in patients with prostate cancer. Further studies are needed to evaluate the clinical value of this novel 3D PET index as a possible future imaging biomarker.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Analytic Validation of the Automated Bone Scan Index as an Imaging Biomarker to Standardize Quantitative Changes in Bone Scans of Patients with Metastatic Prostate Cancer

A reproducible and quantitative imaging biomarker is needed to standardize the evaluation of changes in bone scans of prostate cancer patients with skeletal metastasis. We performed a series of analytic validation studies to evaluate the performance of the automated bone scan index (BSI) as an imaging biomarker in patients with metastatic prostate cancer.

METHODS

Three separate analytic studies were performed to evaluate the accuracy, precision, and reproducibility of the automated BSI. Simulation study: bone scan simulations with predefined tumor burdens were created to assess accuracy and precision. Fifty bone scans were simulated with a tumor burden ranging from low to high disease confluence (0.10-13.0 BSI). A second group of 50 scans was divided into 5 subgroups, each containing 10 simulated bone scans, corresponding to BSI values of 0.5, 1.0, 3.0, 5.0, and 10.0. Repeat bone scan study: to assess the reproducibility in a routine clinical setting, 2 repeat bone scans were obtained from metastatic prostate cancer patients after a single 600-MBq (99m)Tc-methylene diphosphonate injection. Follow-up bone scan study: 2 follow-up bone scans of metastatic prostate cancer patients were analyzed to determine the interobserver variability between the automated BSIs and the visual interpretations in assessing changes. The automated BSI was generated using the upgraded EXINI bone(BSI) software (version 2). The results were evaluated using linear regression, Pearson correlation, Cohen κ measurement, coefficient of variation, and SD.

RESULTS

Linearity of the automated BSI interpretations in the range of 0.10-13.0 was confirmed, and Pearson correlation was observed at 0.995 (n = 50; 95% confidence interval, 0.99-0.99; P < 0.0001). The mean coefficient of variation was less than 20%. The mean BSI difference between the 2 repeat bone scans of 35 patients was 0.05 (SD = 0.15), with an upper confidence limit of 0.30. The interobserver agreement in the automated BSI interpretations was more consistent (κ = 0.96, P < 0.0001) than the qualitative visual assessment of the changes (κ = 0.70, P < 0.0001) was in the bone scans of 173 patients.

CONCLUSION

The automated BSI provides a consistent imaging biomarker capable of standardizing quantitative changes in the bone scans of patients with metastatic prostate cancer.

Analysis of regional bone scan index measurements for the survival of patients with prostate cancer

Background

A bone scan is a common method for monitoring bone metastases in patients with advanced prostate cancer. The Bone Scan Index (BSI) measures the tumor burden on the skeleton, expressed as a percentage of the total skeletal mass. Previous studies have shown that BSI is associated with survival of prostate cancer patients. The objective in this study was to investigate to what extent regional BSI measurements, as obtained by an automated method, can improve the survival analysis for advanced prostate cancer.

Methods

The automated method for analyzing bone scan images computed BSI values for twelve skeletal regions, in a study population consisting of 1013 patients diagnosed with prostate cancer. In the survival analysis we used the standard Cox proportional hazards model and a more advanced non-linear method based on artificial neural networks. The concordance index (C-index) was used to measure the performance of the models.

Results

A Cox model with age and total BSI obtained a C-index of 70.4%. The best Cox model with regional measurements from Costae, Pelvis, Scapula and the Spine, together with age, got a similar C-index (70.5%). The overall best single skeletal localisation, as measured by the C-index, was Costae. The non-linear model performed equally well as the Cox model, ruling out any significant non-linear interactions among the regional BSI measurements.

Conclusion

The present study showed that the localisation of bone metastases obtained from the bone scans in prostate cancer patients does not improve the performance of the survival models compared to models using the total BSI. However a ranking procedure indicated that some regions are more important than others.

A novel automated platform for quantifying the extent of skeletal tumour involvement in prostate cancer patients using the Bone Scan Index

BACKGROUND

There is little consensus on a standard approach to analysing bone scan images. The Bone Scan Index (BSI) is predictive of survival in patients with progressive prostate cancer (PCa), but the popularity of this metric is hampered by the tedium of the manual calculation.

OBJECTIVE

Develop a fully automated method of quantifying the BSI and determining the clinical value of automated BSI measurements beyond conventional clinical and pathologic features.

DESIGN, SETTING, AND PARTICIPANTS

We conditioned a computer-assisted diagnosis system identifying metastatic lesions on a bone scan to automatically compute BSI measurements. A training group of 795 bone scans was used in the conditioning process. Independent validation of the method used bone scans obtained ≤3 mo from diagnosis of 384 PCa cases in two large population-based cohorts. An experienced analyser (blinded to case identity, prior BSI, and outcome) scored the BSI measurements twice. We measured prediction of outcome using pretreatment Gleason score, clinical stage, and prostate-specific antigen with models that also incorporated either manual or automated BSI measurements.

MEASUREMENTS

The agreement between methods was evaluated using Pearson's correlation coefficient. Discrimination between prognostic models was assessed using the concordance index (C-index).

RESULTS AND LIMITATIONS

Manual and automated BSI measurements were strongly correlated (ρ=0.80), correlated more closely (ρ=0.93) when excluding cases with BSI scores≥10 (1.8%), and were independently associated with PCa death (p<0.0001 for each) when added to the prediction model. Predictive accuracy of the base model (C-index: 0.768; 95% confidence interval [CI], 0.702-0.837) increased to 0.794 (95% CI, 0.727-0.860) by adding manual BSI scoring, and increased to 0.825 (95% CI, 0.754-0.881) by adding automated BSI scoring to the base model.

CONCLUSIONS

Automated BSI scoring, with its 100% reproducibility, reduces turnaround time, eliminates operator-dependent subjectivity, and provides important clinical information comparable to that of manual BSI scoring.

Improved classifications of planar whole-body bone scans using a computer-assisted diagnosis system: a multicenter, multiple-reader, multiple-case study

The aim of this multicenter study was to investigate whether a computer-assisted diagnosis (CAD) system could improve performance and reduce interobserver variation in bone-scan interpretations of the presence or absence of bone metastases.

METHODS

The whole-body bone scans (anterior and posterior views) of 59 patients with breast or prostate cancer who had undergone scintigraphy for suspected bone metastatic disease were studied. The patients were selected to reflect the spectrum of pathology found in everyday clinical work. Thirty-five physicians working at 18 of the 30 nuclear medicine departments in Sweden agreed to participate. The physicians were asked to classify each case for the presence or absence of bone metastasis, without (baseline) and with the aid of the CAD system (1 y later), using a 4-point scale. The final clinical assessments, based on follow-up scans and other clinical data including the results of laboratory tests and available diagnostic images (such as MRI, CT, and radiographs from a mean follow-up period of 4.8 y), were used as the gold standard. Each physician's classification was pairwise compared with the classifications made by all the other physicians, resulting in 595 pairs of comparisons, both at baseline and after using the CAD system.

RESULTS

The physicians increased their sensitivity from 78% without to 88% with the aid of the CAD system (P < 0.001). The specificity did not change significantly with CAD. Percentage agreement and kappa-values between paired physicians on average increased from 64% to 70% and from 0.48 to 0.55, respectively, with the CAD system.

CONCLUSION

A CAD system improved physicians' sensitivity in detecting metastases and reduced interobserver variation in planar whole-body bone scans. The CAD system appears to have significant potential in assisting physicians in their clinical routine.

Computer-assisted interpretation of planar whole-body bone scans

The purpose of this study was to develop a computer-assisted diagnosis (CAD) system based on image-processing techniques and artificial neural networks for the interpretation of bone scans performed to determine the presence or absence of metastases.

METHODS

A training group of 810 consecutive patients who had undergone bone scintigraphy due to suspected metastatic disease were included in the study. Whole-body images, anterior and posterior views, were obtained after an injection of (99m)Tc-methylene diphosphonate. The image-processing techniques included algorithms for automatic segmentation of the skeleton and automatic detection and feature extraction of hot spots. Two sets of artificial neural networks were used to classify the images, 1 classifying each hot spot separately and the other classifying the whole bone scan. A test group of 59 patients with breast or prostate cancer was used to evaluate the CAD system. The patients in the test group were selected to reflect the spectrum of pathology found in everyday clinical work. As the gold standard for the test group, we used the final clinical assessment of each case. This assessment was based on follow-up scans and other clinical data, including the results of laboratory tests, and available diagnostic images, such as from MRI, CT, and radiography, from a mean follow-up period of 4.8 y.

RESULTS

The CAD system correctly identified 19 of the 21 patients with metastases in the test group, showing a sensitivity of 90%. False-positive classification of metastases was made in 4 of the 38 patients not classified as having metastases by the gold standard, resulting in a specificity of 89%.

CONCLUSION

A completely automated CAD system can be used to detect metastases in bone scans. Application of the method as a clinical decision support tool appears to have significant potential.

Quality of planar whole-body bone scan interpretations--a nationwide survey

PURPOSE

The purpose of this study was to investigate, in a nationwide study, the inter-observer variation and performance in interpretations of bone scans regarding the presence or absence of bone metastases.

METHODS

Bone scan images from 59 patients with breast or prostate cancer, who had undergone scintigraphy due to suspected bone metastatic disease, were studied. The patients were selected to reflect the spectrum of pathology found in everyday clinical work. Whole body images, anterior and posterior views, were sent to all 30 hospitals in Sweden that perform bone scans. Thirty-seven observers from 18 hospitals agreed to participate in the study. They were asked to classify each of the patient studies regarding the presence of bone metastasis, using a four-point scale. Each observer's classifications were pairwise compared with the classifications made by all the other observers, resulting in 666 pairs of comparisons. The interpretations of the 37 observers were also compared with the final clinical assessment, which was based on follow-up scans and other clinical data.

RESULTS

On average, two observers agreed on 64% of the bone scan classifications. Kappa values ranged between 0.16 and 0.82, with a mean of 0.48. Sensitivity and specificity for the observers compared with the final clinical assessment were 77% and 96%, respectively, for detecting bone metastases in planar whole-body bone scanning.

CONCLUSION

Moderate inter-observer agreement was found when observers were compared pairwise. False-negative errors seem to be the major problem in the interpretations of bone scan images, whilst the specificities for the observers were high.

A new computer-based decision-support system for the interpretation of bone scans

OBJECTIVE

To develop a completely automated method, based on image processing techniques and artificial neural networks, for the interpretation of bone scans regarding the presence or absence of metastases.

METHODS

A total of 200 patients, all of whom had the diagnosis of breast or prostate cancer and had undergone bone scintigraphy, were studied retrospectively. Whole-body images, anterior and posterior, were obtained after injection of 99mTc-methylene diphosphonate. The study material was randomly divided into a training group and a test group, with 100 patients in each group. The training group was used in the process of developing the image analysis techniques and to train the artificial neural networks. The test group was used to evaluate the automated method. The image processing techniques included algorithms for segmentation of the head, chest, spine, pelvis and bladder, automatic thresholding and detection of hot spots. Fourteen features from each examination were used as input to artificial neural networks trained to classify the images. The interpretations by an experienced physician were used as the 'gold standard'.

RESULTS

The automated method correctly identified 28 of the 31 patients with metastases in the test group, i.e., a sensitivity of 90%. A false positive classification of metastases was made in 18 of the 69 patients not classified as having metastases by the experienced physician, resulting in a specificity of 74%.

CONCLUSION

A completely automated method can be used to detect metastases in bone scans. Future developments in this field may lead to clinically valuable decision-support tools.

Improved stroke volume assessment in the aortic and mitral valves with a new method in subjects without regurgitation

BACKGROUND

Echocardiography combining Doppler and two-dimensional data is recommended for quantitative assessments of valvular regurgitation. We applied a new method to calculate the mitral annulus (MA) area in combination with multiple sample sites. Individuals without regurgitation in whom the valvular and left ventricular stroke volumes (SV) should be identical were investigated in order to evaluate the feasibility in quantitative assessments of valvular regurgitation.

METHODS AND RESULTS

Twenty subjects were included. Flow velocity was registered with pulsed Doppler in different positions in the left ventricular outflow tract (LVOT) and in the MA. The MA area was assumed to be either circular, using the diameter from a four-chamber projection, or elliptic, using the major diameter from a parasternal short axis and a minor diameter from an apical long axis. Left ventricular (LV) SV was measured from LV volumes using the biplane method. The overall difference between LVOT SV and mitral SV using one centrally located measurement and elliptic MA was 3.2+/-15.6 ml (P=0.38), 0.9+/-15.7 ml between LVOT SV and LV SV (P=0.80) and -2.2+/-15.2 ml between mitral SV and LV SV (P=0.54). The corresponding standard deviation of the differences as a percentage of the mean value was 24%, 25% and 23%. A circular shaped MA overestimated the mitral SV compared with LVOT SV (P=0.009) and LV SV (P=0.004). Increasing the number of sample sites in the LVOT or MA did not further improve the results.

CONCLUSION

Doppler and two-dimensional echocardiography can be used to quantify regurgitation in groups of patients. In individual patients the wide distribution of differences between valves and LV SV implies that the method should be used in conjunction with other Doppler echocardiographic parameters.

Portal Drained Visceral Flux, Hepatic Metabolism, and Mammary Uptake of Free and Peptide-Bound Amino Acids and Milk Amino Acid Output in Dairy Cows Fed Diets Containing Corn Grain Steam Flaked at 360 or Steam Rolled at 490 g/L

Objectives were to measure net fluxes of free (FAA) and peptide bound amino acids (AA) (PBAA) across portal-drained viscera (PDV), liver, splanchnic, and mammary tissues, and of milk AA output of lactating Holstein cows (n = 6, 109 +/- 9 d in milk) as influenced by flaking density of corn grain. Cows were fed alfalfa-based total mixed ration (TMR) containing 40% steam-flaked (SFC) or steam-rolled corn (SRC) grain. The TMR were offered at 12-h intervals in a crossover design. Six sets of blood samples were obtained from indwelling catheters in portal, hepatic, and mammary veins and mesenteric or costoabdominal arteries every 2 h from each cow and diet. Intake of dry matter (18.4 +/- 0.4 kg/d), N, and net energy for lactation were not altered by corn processing. Milk and milk crude protein yields (kg/12-h sampling) were 14.2 vs. 13.5 and 0.43 vs. 0.39 for cows fed SFC or SRC, respectively. The PDV flux of total essential FAA was greater (571.2 vs. 366.4 g/12 h, SEM 51.4) in cows fed SFC. The PDV flux of total essential PBAA was 69.3 +/- 10.8 and 51.5 +/- 13.2 g/12 h for cows fed SFC and SRC, respectively, and differed from zero, but fluxes of individual PBAA rarely differed between treatments. Liver flux of essential FAA was greater in cows fed SRC, but only the PBAA flux in cows fed SRC differed from zero. Splanchnic flux of FAA and PBAA followed the pattern of PDV flux, but variation was greater. Mammary uptake (g/12 h) of total essential FAA was greater in cows fed SFC than SRC (224.6 vs. 198.3, SEM 7.03). Mammary uptake of essential PBAA was 25.0 vs. 15.1, SEM 5.2, g/12 h for cows fed SFC or SRC, respectively, and differed from zero in half of the PBAA. Milk output of EAA was 187.8 vs 175.4, SEM 4.4 g/12 h in cows fed SFC and SRC, respectively, and output of most essential AA consistently tended to be greater in cows fed SFC. It is apparent that PBAA comprise a portion of total AA flux across PDV and are affected by grain processing. Further, this pool supplies an important component of AA taken up by the mammary gland. Quantifying the contribution of PBAA may improve diet formulation with respect to intestinal absorption and mammary uptake of AA.

Splanchnic and mammary nitrogen metabolism by dairy cows fed dry-rolled or steam-flaked sorghum grain

Objectives were to determine net release or uptake of alpha-amino N, ammonia N, and urea N across portal-drained viscera, liver, splanchnic, and mammary tissues of lactating Holstein cows (n = 8, 86 +/- 8 d in milk) fed alfalfa hay-based total mixed rations containing 40% dry-rolled or steam-flaked sorghum grain. The total mixed rations were offered at 12-h intervals in a crossover design. Blood samples were obtained from indwelling catheters in the portal, hepatic, and mammary veins and mesenteric or costoabdominal arteries, every 2 h for each cow and diet. Steam-flaking increased in vitro rate of starch hydrolysis compared with dry-rolled sorghum (66 vs. 25%). Diet did not alter dry matter intake (18.2 +/- 0.3 kg). Daily milk yield (27.6 +/- 0.8 kg), efficiency of production, and most milk components did not differ between diets, but fat yield was reduced (0.86 vs. 0.91 kg/d) by steam-flaked sorghum, and lactose concentration was increased (4.99 vs. 4.82%). Blood flows in portal and hepatic veins did not differ between diets. Steam-flaking tended to increase urea N cycling to the gut (162 vs. 95 g/d) compared with dry-rolling of sorghum, whereas net absorption of ammonia N and alpha-amino N across portal-drained viscera were decreased. Net mammary uptake of a-amino N increased more than 20% (83 vs. 67 g/d), resulting in a higher mammary extraction ratio (15 vs. 11%) for steam-flaked versus dry-rolled sorghum. Flaking of sorghum improved the efficiency of postabsorptive N metabolism by increasing urea N cycled to the gut and alpha-amino N uptake by the mammary gland.

Splanchnic and mammary nitrogen metabolism by dairy cows fed steam-rolled or steam-flaked corn

Objectives were to determine net release or uptake of a-amino N, ammonia N, and urea N across portal-drained viscera, liver, splanchnic, and mammary tissues of lactating Holstein cows (n = 6; 109 +/- 9 d in milk) fed alfalfa hay-based total mixed rations (TMR) containing 40% steam-rolled or steam-flaked corn grain. The TMR were offered at 12-h intervals in a crossover design. Blood samples were obtained from indwelling catheters in portal, hepatic, and mammary veins and mesenteric or costo abdominal arteries, every 2 h for each cow and diet. Steam-flaked compared with steam-rolled corn greatly increased in vitro starch hydrolysis (56 vs. 34%). Daily intake of dry matter (18.4 +/- 0.4 kg/d), starch, N, and net energy for lactation by cows were not altered by processing corn; neither were daily yield of milk (29.1 +/- 0.7 kg/d), fat-corrected milk, nor fat-corrected milk per dry matter intake. Steam-flaking tended to increase percent milk protein (2.97 vs. 2.82%; P = 0.07), but not yield, and decrease percent lactose (4.83 vs. 4.94) but not yield. Portal and hepatic blood flows were not affected by diet, nor were net absorption of alpha-amino N and ammonia N. Steam-flaking compared with steam-rolling increased urea N cycling to portal-drained viscera (212 vs. 87 g/d) by 140%, estimated mammary uptake and extraction ratio of alpha-amino N. Flaking versus rolling of corn improved N utilization in dairy cows by increasing urea cycling to the gut and uptake of a-amino N by the mammary gland. Higher mammary uptake of alpha-amino N (78 vs. 50 g/d) by dairy cows fed steam-flaked corn tended to increase milk protein content and may explain the previously observed effects of cows fed steam-flaked versus steam-rolled corn.

Net absorption and hepatic metabolism of glucose, L-lactate, and volatile fatty acids by steers fed diets containing sorghum grain processed as dry-rolled or steam-flaked at different densities

We determined the effect of processing method (dry-rolled [DR] vs steam-flaked [SF]) and degree of processing (flake density; FD) of SF sorghum grain on splanchnic (gut and liver) metabolism of energy-yielding nutrients by growing steers. Diets contained 77% sorghum grain, either DR or SF, with SF at densities of 437, 360, or 283 g/L (SF34, SF28, or SF22). Eight multicatheterized steers (340 kg initial BW) were used in a randomized complete block design. Net output or uptake of glucose, L-lactate, VFA, and beta-hydroxybutyrate (BHBA) were measured across portal-drained viscera (PDV), liver, and splanchnic (PDV plus liver) tissues. Net absorption of glucose across PDV was negative and similar for all treatments (average of -104 g/d). Decreasing FD of SF sorghum grain linearly increased (P < or = .04) net absorption and splanchnic output of L-lactate by 20 and 130%, respectively, and hepatic synthesis (P = .06) and splanchnic output (P = .01) of glucose by 50%. Reducing FD did not alter output or uptake of acetate or n-butyrate by gut and liver tissues, but linearly decreased (P = .06) splanchnic output of BHBA by 40%. Net absorption (P = .18) and splanchnic output (P = .15) of propionate tended to be increased linearly by 50% with decreasing FD. Neither processing method (SF vs DR) nor degree of processing (varying FD) altered hepatic nutrient extraction ratios or estimated net absorption and splanchnic output of energy. Maximal contribution of propionate, L-lactate, and amino acids (alpha-amino N) to gluconeogenesis averaged 49, 11, and 20%, respectively. Feeding steers SF compared to DR diets did not alter net output or uptake of energy-yielding nutrients across splanchnic tissues, except net absorption of acetate tended to be greater (P = .13) for steers fed DR. Increasing degree of grain processing in the present study, by incrementally decreasing FD, tended to linearly increase the net absorption of glucose precursors (propionate and lactate), resulting in linear increases in synthesis and output of glucose by the liver to extrasplanchnic tissues (e.g., muscle).

Steam-processed corn and sorghum grain flaked at different densities alter ruminal, small intestinal, and total tract digestibility of starch by steers

Crossbred steers (n = 7; 400 kg BW), fitted with T-type cannulas in the duodenum and ileum, were used to examine the effects of processing method, dry-rolled (DR) vs. steam-flaked (SF) sorghum grain, and degree of processing (flake density; FD) of SF corn (SFC) and SF sorghum (SFS) grain on site and extent of DM, starch, and N digestibilities and to measure extent of microbial N flow to the duodenum. In Exp. 1, diets contained 77% DRS or 77% SFS with FD of 437, 360, and 283 g/L (SF34, SF28, and SF22). In Exp. 2, diets contained 77% SFC with FD of SF34 or SF22. For sorghum and corn diets, respective average daily intakes were as follows: DM, 6.7 and 8.1 kg; starch, 3.8 and 4.7 kg; N, 136 and 149 g. Steers fed SFS vs. DRS increased (P = .01) starch digestibilities (percentage of intake) in the rumen (82 vs. 67%) and total tract (98.9 vs. 96.5%) and decreased digestibilities in the small intestine (16 vs. 28%; P = .01) and large intestine (.5 vs 1.2%; P = .05). As a percentage of starch entering the segment, digestibility was increased (P = .01) within the small intestine (91 vs. 85%) but was not altered within the large intestine by steers fed SFS vs. DRS. Decreasing FD of SFS and of SFC, respectively, linearly increased starch digestibilities (percentage of intake) in the rumen (P = .03, .02) and total tract (P = .03, .09) and linearly diminished starch digestibilities in the small intestine (P = .04, .09). Starch digestibilities (percentage of entry) within the small or large intestine were not changed by FD. The percentage of dietary corn or sorghum starch digested in the large intestine was very small, less than 2% of intake. Microbial N flow to the duodenum was not altered by SFS compared to DRS, or by decreasing FD of SFS and SFC. Reducing FD of SFS, but not of SFC, tended to decrease (P = .07) microbial efficiency linearly and tended to increase (P = .06) total tract N digestibilities linearly. Steam flaking compared to dry rolling of sorghum grain and decreasing FD of SFC and SFS grain consistently increased starch digestibility in the rumen and total tract of growing steers. The greatest total digestibility of dietary starch occurred when the proportion digested in the rumen was maximized and the fraction digested in the small intestine was minimized. These changes in sites of digestion account, in part, for the improved N conservation and greater hepatic output of glucose by steers fed lower FD of SFS reported in our companion papers.

Influence of yucca extract on ruminal metabolism in cows

Two trials were conducted to determine the influence of yucca extract on ruminal digestion, fermentation, and ammonia patterns using ruminally and duodenally cannulated dairy cows. In Trial 1, urea at 0 or 1% of the diet and yucca extract at 0 or 4 g/d formed four dietary treatments in a 2 x 2 factorial arrangement. The experimental design was a 4 x 4 Latin square with 15-d periods. Duodenal digesta were sampled every 6 h during the last 4 d of each period to determine OM and ADF digestibilities and bacterial protein synthesis in the rumen using Cr2O3 and 15N markers. Ruminal digestibilities were (percentage): OM 46.3 vs 43.0%, and ADF 35.9 vs 41.4%, with or without Deodorase. Microbial protein entering the duodenum averaged 2.7 vs 3.1 kg/d for the respective treatments. Ruminal measurements were not affected by treatment (P > .10). In Trial 2, five cows were used in a 5 x 5 Latin square with 7-d periods. Treatments were 0, 2, 4, 6, and 8 g/d of yucca extract administered via ruminal cannulas. Ruminal fluid was sampled 0, 1, 2, 4, 7, 11, 16, and 22 h after feeding during the last 2 d of each period. Average ruminal NH3 N ranged from 31.4 to 35.4 mg/dL, pH 5.99 to 6.18, and total VFA from 120 to 129 mM, and all did not differ among treatments (P > .10). Yucca extract administered at 4 g/d did not significantly affect ruminal digestibilities of OM and ADF, and up to 8 g/d did not affect ruminal NH3, pH, or VFA.

Influence of dietary protein sources on the amino acid profiles available for digestion and metabolism in lactating cows

Six lactating Holstein cows, fitted with T-type cannulas in the proximal duodenum, were used in a replicated 3 x 3 Latin square design to determine influence of supplemental protein on amino acid profiles of duodenal chyme and plasma. Protein sources were blood meal, corn gluten meal, and cottonseed meal, which furnished approximately 46% of the total protein in corn-grain corn silage diets. Markers were 15N to estimate rumen bacteria and chromic oxide to estimate nutrient flow. Dry matter intake was lowest on blood meal. Duodenal flow of N exceeded N intake 23% on blood meal and corn gluten meal. Percentages of organic matter and protein digested in the rumen were 56.5, 41.8; 61.2, 53.4; and 50.6, 56.2 for the respective diets. Variation in patterns of amino acids flowing to the duodenum, but not in coccygeal blood, closely reflected dietary differences with six of eight essential amino acids highest for the same treatment in both diet and duodenal chyme. Essential amino acids in least abundance for milk production, measured by mammary extraction coefficients, differed among diets. We conclude that supplemental protein source influences greatly the quantity and pattern of amino acids available for digestion in lactating dairy cows.